ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Secondary intention, for wounds like burns, leaves severe scarring (Choice D), per the text, as open wounds fill with scar tissue, potentially impairing function. Minimal tissue loss and minimal scarring suit primary intention. Dark redness isn't typical. Severe scarring reflects the healing process's extent, a key observation nurses document, making this the correct indicator of secondary intention healing.
Question 2 of 5
Which next step will the nurse anticipate for a pressure ulcer that is black?
Correct Answer: C
Rationale: Black tissue is necrotic, requiring debridement (Choice C), per the text, to remove infection sources and promote healing. Monitoring delays care. Documentation follows action. Drainage isn't primary. Debridement clears the wound bed, making this the correct anticipated step.
Question 3 of 5
Which nursing diagnosis will the nurse assign to a patient with a reddened, nonblanchable area on the right heel?
Correct Answer: B
Rationale: Nonblanchable redness signals impaired blood flow, fitting 'Ineffective peripheral tissue perfusion' (Choice B), per the text, as oxygen delivery falters. Nutrition isn't indicated. Infection and pain may follow but aren't primary. This diagnosis targets circulation, making it the correct assignment.
Question 4 of 5
Which is the best method for repositioning an immobile patient to decrease the formation of pressure ulcers?
Correct Answer: B
Rationale: Repositioning reduces shear and friction. Using a transfer device to lift (Choice B), per the text, prevents dragging, which damages skin layers in immobile patients. A 30-degree supine position misaligns with the recommended 30-degree lateral tilt to offload pressure points. Elevating the bed 45 degrees increases shear risk, not reduces it. Sliding causes friction, worsening skin stress. Lifting with devices like slide sheets or hoists is evidence-based, minimizing trauma and ensuring safe pressure relief every 2 hours, making this the correct method for nurses to implement.
Question 5 of 5
Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed for a patient with an initial score of 15?
Correct Answer: D
Rationale: The Braden Scale (6-23) predicts pressure ulcer risk; higher scores indicate lower risk. A score of 23 (Choice D), per the text, is perfect, showing no deficits in sensory perception, moisture, activity, mobility, nutrition, or friction/shear eliminating breakdown risk. Scores of 12 and 13 signal high risk. A score of 20 is good but not optimal. From 15 (moderate risk), achieving 23 confirms all interventions succeeded, making this the correct sign for nurses to aim for.